Paul Krugman drew my attention to a US report on comparing the quality and cost effectiveness of healthcare systems in seven major countries. The report he referred to was written in the context of the debate in the US on healthcare, but is just as applicable to the UK debate on the future of the NHS. Its summary is as follows:

1 is top rank, 7 lowest.

The UK ranks #2 overall. Hardly surprising since on 11 indicators it ranked in the top 3 on 8, and if quality and access are treated at their combined rather than disaggregated levels then it was in the top 3 on all indicators bar longevity of healthy life.

And all that for a much, much lower cost per head than the US market based system but also less too than everywhere but New Zealand, which ranks pretty poorly on everything but being patient focused.

So what does this say? I suggest that the longevity problem is not a health issue: this is a societal issue. It's the consequence of poor housing, inequality, poor health education, and many more such factors reflected in issues such as high obesity rates related to poor diet: a peculiarly British problem. The NHS cannot solve such problems. It's not reasonable to berate it for failing to do so.

That aside, care is great in the NHS. OK. it's not as patient focused as desired, but as the report says this is an issue where all countries could improve. No doubt that's true, but we trade something important here: price for patient focus. Of course people can be at the core of the NHS, but you seriously increase the cost if you double the time seeing the patient: most of NHS cost is labour. The choice is a straightforward one: you can have a patient focused NHS so long as you're willing to pay for it. If you are not willing to pay for it the patient focus will come at the cost of significantly reduced health outcomes. It's a trade-off that I think most would not make if they were given the choice. I think the NHS has got this right.

But most of all what this report says is that the room for efficiency gains in the NHS looks to be incredibly small. Patient centred activity has already been reduced to save cost. Timeliness has been compromised a little to secure savings. Efficiency is already rated as the highest in these seven countries. That's not surprising, the clear raw data shows that be the case. How, in that case, is the NHS going to deliver massive increases in efficiency in a system that is already operating at way above international standards?

We need to get real: the NHS is already delivering extraordinary value for money. Private sector alternatives are exceptionally expensive, as the US proves, with worse quality outcomes (as the table shows).

I am not saying that the NHS does not need improvement: of course it does. but to suggest that it needs a root and branch reform involving a fundamental restructuring because it is failing, as the Conservatives imply, is not just wrong, it's a straightforward lie.

The truth is that the NHS is actually a stunningly cost-effective supplier of high-quality healthcare, so let's celebrate the fact, and help those working in it to make it even better rather than going out of our way to destroy its structure, the morale of those who work in it, and to overburden them with impossible tasks which they can never fulfil that can only result in worse outcomes for us all.

9 Responses

Thanks for this Richard. You’ve been hinting at it for a while so it’s good that you’ve got hold of a report which supports the viewpoint. I do wish the opposition would state this case as clearly as you’ve done in the next Commons debate…

Too bad you don’t realise that the only way to get round that is to spend twice as much as we do now. Is that what you want? Or would you rather that we had much worse health outcomes so we can all have a nice cup of tea when we go to see the doctor? What’s your choice?

I disagree JayPee. If you have far fewer resources at your disposable than on comparable systems, yet produce favourable outcomes on every deliverable but one, which was admittedly poor but in a non-essential area, you wouldn’t describe this as an ‘appaling indictment’ of the manager. You’d say it was generally very well done but with more attention to be paid to the struggling area.

Fortunately, the example above is real and we don’t have to generalise. We know the struggling area is in patient-centred care, which is perhaps the indicator most directly related to labour intensity. The biggest cost in the NHS (as Richard points out) is labour, and we have fewer resources than comparable systems with which to supply it.

If we were falling behind on the effectiveness and efficiency of care as well then this would point to managerial problems, as you suggest. However these are areas in which the NHS ranks highly. I’m sorry but the evidence points to a health service which is generally well managed but poorly resourced, not the other way around.

Or perhaps of successive governments starting under Thatcher and extended under Blair of using tick box targets to drive the system. In such a management regime staff have to put targets first and patients second with predictably dismal consequences.

I have seen a similar result in industry when a large corporate shareholder imposed inappropriate norms on a subsidiary operating in a diffferent industry than its own mainstream business. When the subsidiary inevitably fell into loss its managment was, of course, blamed for incompetence despite having been very successful prior to being taken over.

And, also interestingly, while New Zealand ranks top on patient-centred care, it comes next to bottom on “equity”.

Rather reminiscent of the whole debate about “choice” in public services… a recipe for the articulate and well-connected (and we know how represents them in Parliament) to get what they want, while the rest get the dregs. With a limited budget, I’d sacrifice selfish ‘me’-centred systems for equity, any day.